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Antikoagulantna terapija

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Antikoagulantna terapija

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    1. Antikoagulantna terapija Ivan Gornik Zavod za intenzivnu medicinu, KBC Zagreb

    2. 2 Coagulation Pathway

    3. Antikoagulantna terpija Heparini Nefrakcionirani heparin LMWH Pentasaharid Varfarin “Novi antikoagulansi” Dabigatran (trombin) – Pradaxa, reg. u RH za prev. Rivaroxaban (Xa) – Xarelto, reg. u RH za prev.

    4. Heparini

    5. Heparini

    6. 6 Coagulation Pathway

    7. LMWH Najvažnija uloga u prevenciji DVT/PE Terapija DVT/PE do uspostave terapijske širine INR Akutni koronarni sindrom Oprez kod ekstrema tjelesne mase Oprez kod renalne insuficijencije Monitoring – anti Xa aktivnost, 4 sata nakon aplikacije Protamin – ne sasvim ucinkovit antidot Podjednako ucinkovit kao NFH u prevenciji i lijecenju DVT/PE Prednosti – ne treba APTV, manje HIT, moguce manje krvarenja

    8. LMWH u dugotrajnoj th. DVT/PE Prema CLOT studiji, dalteparin je bio ucinkovitiji od varfarina u prevenciji recidiva PE u bolesnika s malignom bolesti Preporuca se dugotrajna terapija 3-6 mjeseci s dalteparinom te onda prelazak na VKA Nishioka J, Goodin S (2007). "Low-molecular-weight heparin in cancer-associated thrombosis: treatment, secondary prevention, and survival". Journal of Oncology Pharmacy Practice 

    9. Varfarin

    10. 10 Coagulation Pathway

    11. 11 Coumarin Mechanism of Action

    12. INDIKACIJE Tromboembolijska bolest Duboka venska tromboza Plucna embolija Fibrilacija atrija Umjetni srcani zalisci Prokoagulantna stanja Deficit proteina C Deficit antitrombina FV Leiden Antifosfolipidni sindrom Dilatativna kardiomiopatija Aneurizma LK

    13. Venska tromboembolija U prvoj godini 15-50% recidiva bez AKT LMWH neucinkovit Kratkotrajna oralna AKT neucinkovita Najmanje tri mjeseca

    14. Fibrilacija atrija Paroksizmalna fibrilacija atrija ima isti rizik tromboembolije kao i permamentna Antikoagulantna terapija trebala bi se propisivati ovisno o riziku CHA2DS2-VASc

    16. VKA u FA, metaanaliza RR reduction with VKA was highly significant and amounted to 64%, corresponding to an absolute annual risk reduction in all strokes of 2.7%. When only ischaemic strokes were considered, adjusted-dose VKA use was associated with a 67% RR reduction. many strokes occurring in the VKA-treated patients occurred when patients were not taking therapy or were subtherapeutically anticoagulated. All-cause mortality was significantly reduced (26%) by adjusted-dose VKA vs. control. The risk of intracranial haemorrhage was small. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007;146:857–867.

    17. Preporuka ESC Supported by the results of the trials, VKA treatment should be considered for patients with AF with =1 stroke risk factor(s) provided there are no contraindications, especially with careful assessment of the risk–benefit ratio and an appreciation of the patient's values and preferences. Guidelines for the Management of Atrial Fibrillation, ESC, Europace. 2010;12(10):1360-1420. 

    18. Preporuka ESC

    20. Rizik krvarenja HAS-BLED

    21. Operacija pod VKA treatment should be interrupted ~5 days before surgery subtherapeutic anticoagulation for up to 48 h, without substituting heparin, given the low risk of thrombo-embolism in this period VKA should be resumed at the 'usual' maintenance dose (without a loading dose) on the evening of (or the morning after) surgery  surgery or a procedure where the INR is still elevated (>1.5), the administration of low-dose oral vitamin K (1–2 mg) to normalize the INR may be considered Guidelines for the Management of Atrial Fibrillation, ESC, Europace. 2010;12(10):1360-1420. 

    22. Stent i VKA Current guidelines for ACS and/or percutaneous coronary intervention (PCI) recommend the use of aspirin–clopidogrel combination therapy after ACS, and a stent (4 weeks for a bare-metal stent, 6–12 months for a drug-eluting stent) VKA non-treatment is associated with an increase in mortality and major adverse cardiac events, with no significant difference in bleeding rates prevalence of major bleeding with triple therapy is 2.6–4.6% at 30 days, which increases to 7.4–10.3% at 12 months EAPCI, suggests that drug-eluting stents should be avoided and triple therapy used in the short term, followed by longer therapy with VKA plus a single antiplatelet drug Guidelines for the Management of Atrial Fibrillation, ESC, Europace. 2010;12(10):1360-1420. 

    23. Koronarna bolest i VKA Stable angina - VKA monotherapy should be used, and concomitant antiplatelet therapy should not be prescribed Published data support the use of VKA for secondary prevention in patients with coronary artery disease, and VKA is at least as effective as aspirin

    24. CVI/TIA i novootkrivena FA patients within the first 2 weeks after cardioembolic stroke are at greatest risk of recurrent stroke because of further thrombo-embolism anticoagulation in the acute phase may result in intracranial haemorrhage or haemorrhagic transformation of the infarct uncontrolled hypertension should be managed before antithrombotic treatment is started, and cerebral imaging should exclude haemorrhage absence of haemorrhage – anticoagulation after 2 weeks Haemorrhage - anticoagulation should not be given In patients with AF and acute TIA, anticoagulation treatment should begin as soon as possible in the absence of cerebral infarction or haemorrhage.

    25. Kardioverzija anticoagulation is considered mandatory before elective cardioversion for AF of >48 h or AF of unknown duration anticoagulation is considered mandatory before elective cardioversion for AF of >48 h or AF of unknown duration definite AF <48 h, cardioversion under the cover of UFH administered i.v. followed by infusion or subcutaneous LMWH. In patients with risk factors for stroke, OAC should be started after cardioversion and continued lifelong. UFH or LMWH continued until the INR is at the therapeutic level AF > 48 h & haemodynamic instability (UA, MI, shock, or pulmonary oedema), immediate cardioversion with UFH or LMWH before cardioversion. After cardioversion, OAC should be started and heparin should be continued until the INR is at the therapeutic level Duration of OAC therapy (4 weeks or lifelong) will depend on the presence of risk factors for stroke

    26. Umjetne valvule

    28. Previsoki INR Pristup ovisi o klinickoj slici, manje o brojevima

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